MA. LAARNI U.

FELIPE

NURSING CASE STUDY

ADMISSION/FINAL DIAGNOSIS
Admission Diagnosis: Pulmonary mass Left Upper Lobe T/C Lymphoma
Final Diagnosis: Pulmonary mass Left Upper Lobe T/C Lymphoma, HTN
Controlled

I.

HEALTH HISTORY AND PHYSICAL EXAMINATION

A. DEMOGRAPHIC (BIOGRAPHICAL DATA)
1.

Clients name or Initial: R. M. L.

2.

Gender: Male

3.

Age, Birth date and Birthplace: 63 years old / March 12, 1947 /
Batangas City

4.

Marital (Civil) Status: Married

5.

Race and Nationality: Asian / Filipino

6.

Religion: Roman Catholic

7.
Address and Telephone Number, E-mail Address: Purok 6, Sicat,
Alfonso, Cavite/ 0910-575-7056
8.
Graduate

Educational Background / Other Significant Framing: Highschool

9.

Occupation: Farming

10.

Usual Source of Medical Care: Brgy. Health Centre and Physician

B. SOURCE AND RELIABILITY OF INFORMATION

Patient N.C.A. himself who was competent and logical to provide concrete
information; he was able to speak clearly; conscious and coherent.

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Patients mother who was reliable, competent and knowledgeable to provide

significant data about the patient; client was able to speak clearly and express
herself plausible.
Patients chart was able to provide comprehensive and reliable information
about the patient. This serves as the tertiary source of information.
C. REASONS FOR SEEKING CARE OF CHIEF COMPLAINTS
Body pain / back pain
D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH
History revealed I year PTC, a pimple like mass developed on the back area
of the patient. He opted to squeeze it out and found a whitish discharge coming out.
3 months PTC pain over the back area was felt and the mass enlarges over time.
Pain radiates to the upper extremities and lower back area as well as in the anterior
thorax. Back pain was rated as 7/ 10 (severe pain). Patient consulted doctors for 4
times and was prescribed with multivitamins, Celecoxib, Prednisone. 2 hours PTC,
the patient experienced the recurrence of the back pain now with a grade of 10/10,
no relief with Celecoxib and Prednisone hence consulted at De La Salle University
Medical Center and was subsequently admitted on November 8, 2010 around 6
oclock pm for further management.
E. PAST MEDICAL HISTORY OR PAST HEALTH
Patient had pediatric illnesses like small pox, fever, cough, flu and sore eyes.
Patient had no history of accidents or injuries. This is the second hospitalization of
the patient. The first hospitalization happened around 2 years ago due to an
enlarged goiter and during this period he had a major operation which was
thyroidectomy. The patient was unable to recall the immunizations he received.
Patient has no allergies to foods, drugs, chemicals or other environmental allergens.
Some of the OTC drugs the patient buys are Neozep, Biogesic and Dolfenal. The
patient was able to enumerate some of the drugs he is taking as of now such as the
Losartan and Etoricoxib. Last examination date was one week ago (November
3,2010) to Dr. Olympo.
F. FAMILY HISTORY
(see separate page)

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G. SOCIO-ECONOMIC HISTORY
FAMILY
MEMBER
Patient
Wife
Son
Daughter in law
Granddaughter
Grandson

OCCUPATION/ SOURCE OF
INCOME
Farmer
Housewife
Employee
Employee
N/A
N/A

MONTHLY INCOME
3,000 8,000
N/A
7,000 10,000
4,000- 8,000
N/A
N/A

Patient owns and manages a small farm in which he tends crops such as
tomatoes, potatoes, cabbages, and bitter gourd. He also rears livestock such as
chicken and pigs to provide additional income to the family and also to be used as
their food. The patients wife attends to the house chores such as cooking, washing
clothes and cleaning their home. Patients son and daughter-in-law work as
employees at a company and contribute a lot to the family income. Patients wife
declared that their daily basic needs are adequately accommodated. Since the
income is only enough to suffice their needs, shortage occurs when emergency
cases arise.
Although the condition of the patient is a major blow to the family, they are
coping and contributing for the betterment of his condition and hopes for him to
recuperate.
H. PSYCHOSOCIAL ASSESSMENT
The patient is 63 years old, male which falls under Erik Eriksons
psychosocial development category of Generativity vs. Stagnation. The basic
strength on this stage is care with the main question of: Will I produce something of
real value?
Generativity is the concern of establishing and guiding the next generation.
Socially-valued work and disciplines are expressions of generativity. Simply having
or wanting children does not in and of itself achieve generativity. During middle age
the primary developmental task is one of contributing to society and helping to guide
future generations. When a person makes a contribution during this period, perhaps
by raising a family or working toward the betterment of society, a sense of
generativity (a sense of productivity and accomplishment) results. In contrast, a
person who is self-centered and unable or unwilling to help society move forward
develops a feeling of stagnation dissatisfaction with the relative lack of productivity.
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In patients present life, he has one son who is married and has two
grandchildren. He trained his son who is now a father to be a responsible adult. He
accepts without any repugnance his sons wife and friends. He ensures that he
creates a comfortable home with his wife by giving love and care and having time or
each other. They are united in all the things of their life and really love each other.
Although, he was unable to finish his education he is a proud to have a simple family
and is pleased with his livelihood. He displays affirmative signs of this stage: such as
adjusting to the physical changes of middle age (thinning hair) and achieving a
mature, civic and social responsibility by promoting the goodness of majority.
Therefore, the patient develops generativity rather than stagnation.
I.

REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

Date of Examination: November 9, 2010

SYSTEM
a. General

R.O.S.
Sobrang sakit ng likod ko.
Hirapa kong magpalit ng
posisyon. Siguro nasa 9 yung
sakit.

P.E.
Alert and cooperative.

Hindi ko alam kung ano ang

timbang ko eh. Hindi ko kasi
nakukuha kaya di ko alam
kung nadaragdagan o
nababawasan ang timbang
ko.

(+) nodular mass on the

back approximately 2x3 cm
non-erythematous, nonmovable and tender to touch

Dressed appropriately for

the occasion: jeans and polo
shirt

Rated pain as 9/10 in a

scale of 0-10
(where 0=no pain, 1-3=mild
pain, 4-6= moderate pain
and 7-10 is severe pain)
(+) guarding behavior
(+) facial grimace
(+) weakness and limitation
of movement
Vital signs results:
Temp(axillary): 36.1oC
PR: 70 bpm
RR: 20 cpm
BP: 110/70 mmHg
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SKIN
b. Integument

Wala naman akong sakit sa

balat. Nagkaroon lang ako dati
ng parang tigyawat sa likod
tapos pinisa ko. Wala namang
pagbabago sa buhok ko at
mga nunal. Naliligo ako isang
beses sa loob ng isang araw
gamit ang tubig at sabon.

Inspection

(+) nodular mass on the

back approximately 2x3
cm non-erythematous,
non-movable and tender
to touch
Texture : smooth and
firm, not dry
Warm to touch
Color : light brown
consistent throughout the
body
(-) pallor
(-) cyanosis
(-) jaundice
(-) wrinkles
(-) skin lesions
(-) eczema
(-) psoriasis
(-) hives
Palpation

(+) good skin turgor

(-) edema
NAILS
Inspection

Nail plate is attached at

the nail bed
Characteristics : pink in
color
Nail is short and well
trimmed.
Palpation
Nail is hard, smooth and
immobile.
Capillary refill : 2-3
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seconds
HAIR
Inspection

Color : white
Palpation

Fine and pliant in texture

Inspection

c. Head

Hindi naman masakit ang ulo

ko, hindi rin nahihilo at saka
hindi pa ako nagkakaroon ng
aksidente sa ulo.

Head is round.
Symmetrical facial
features
No limitations of
movement.
(-) lesions
Palpation

Hard and free from

lumps and masses.
Inspection

d. Eyes

Wala namang pagbabago sa

paningin ko. Hindi ako
gumagamit ng salamin.Hindi
naman masakit ang mga mata
ko.

e. Ears

Wala naman akong problema

Equal in size and shape

bilaterally.
Brown iris, sclera is
white.
Round and symmetrical
in shape.
Eyelashes are short,
evenly spaced and
curled outward
(+) bilateral blinking
reflex
(-) lesions, scarring and
inflammation.
(-) diplopia
(-) excessive tearing
(-) redness
PERRLA
(-) pus drainage
Inspection
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sa pandinig ko. Hindi pa ako
nagkakaroon ng impeksiyon sa
tenga.Hindi rin ako gumagamit
ng mga hearing aid.Naglilinis
ako ng tenga isang beses sa
loob ng dalawang araw gamit
ang cotton buds.

Equal in size and equal

bilaterally.
Symmetrical
Well distributed skin
color.
(-) drainage or lesions
Palpation
Warm to touch
Non-tender

NOSE
Inspection

f. Nose and
Sinuses

Hindi naman masakit ang

ilong ko.
Dati may lumabas na dugo sa
ilong ko sa sobrang init pero
ngayon wala naman.

Even skin color.

Proportioned to facial
structure.
Septum is positioned at
midline
(-) nasal flaring
(-) epistaxis
(-) itching
Palpation

Smooth and non-tender

(-) nodules
(-) masses
SINUSES

g. Mouth and
Throat

Wala namang masakit, wala

ring pagbabago sa boses at
panlasa ko. Nakapustiso na
yung mga nasa taas yung mga
nasa baba hindi pa. Isang
beses ako kung maglinis ng
ngipin sa loob ng isang araw.

Non-tender upon
palpation.
Inspection

MOUTH
(-) lesions and ulcerations.
Buccal mucosa is pink in
color
(-) bleeding gums
LIPS
pink in color
(-) sores
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(-) lesions
TONGUE

Moist and pink in color

(-) lesions or ulcerations
TEETH

Incomplete set of teeth.

(+) use of dentures
Yellowish in color
THROAT

(-) redness and inflammation

of the tonsil
Palpation

h. Neck

Trachea is straight and

located on midline of the
throat.
Inspection
(+) limited movement of
neck
Palpation

Hindi ko maigalaw maigi ang

leeg ko kasi sa sakit ng likod
ko hindi ko kaya na humiga sa No palpable lymph nodes,
likod. Nakatagilid lang ako
carotid artery are bilaterally
lagi.
equal in pulsation and
rhythm.
(-) lumps and swelling
Inspection

i. Breast and
Axilla

Wala namang problema,

walang masakit.

Nipples are at the same

level on the chest and
brown in color.
AXILLA

Presence of axillary
hairs.
(-) lesions and scarring
j. Respiratory

Hindi naman ako

nahihirapang huminga at wala
akong ubo, sinisipon lang.
Kakakuha lang sa akin ng

Inspection
THORAX

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symmetrical expansion.
(-) use of accessory muscle
(-) sputum
(-) cyanosis
(-) dry cough
(-) hemoptysis
(-) Barrel chest
Palpation
Chest CT Scan.

(-) masses
Percussion

resonant
Auscultation

(-) wheezes
(-) crackles
RR: 20 cpm
Inspection
(-) bounding jugular vein
pulsation
(-) fatigue
(-) dizziness
Palpation

k. Cardiovascular

Hindi naman ako nahihirapan

sa mga pang-araw araw na
gawain nung wala pa tong
sakit sa likod ko.Wala naman Radial and apical pulse are
akong napapansing
identical
pagbabago sa kulay ng kamay
at paa ko, ganun pa rin naman PR: 70 bpm
Auscultation
hindi maputla.
(-) bradycardia
(-) tachycardia
BP: 110/70 mmHg

l.Gastrointestinal

Maayos naman ang pagkain

ko. Nauubos ko yung pagkain
dito sa ospital. Hindi naman
ako nasusuka. Wala namang
masakit sa tiyan ko.Dumudumi
ako isa o dalawang beses sa
loob ng isang araw, wala
namang pagbabago sa kulay
at tekstura. Kulay lupa siya at

Inspection
Umbilicus is centrally
located
(+) scaphoid abdomen
No movement or slight
pulsation visualized over
aorta.
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hindi matubig.

(-) diarrhea
(-) rectal bleeding
(-) nausea and vomiting
Auscultation
18-20times/min bowel
sounds
Percussion

Generalized
tympany
over bowels
Palpation

(-) tenderness and masses

in 4 quadrants of the
abdomen.
Inspection

m. Urinary

Umiihi ako mga tatlo

hanggang 4 na beses sa loob
ng isang araw. Hindi naman
ako nahihirapan sa pagihi at
wala namang masakit. Yung
kulay naman ng ihi ko ganun
pa rin dilaw hindi mapula.

n. Genitalia

Not asked in the interview

o.
Musculoskeletal

Hirap akong magpalit ng

posisyon dahil sa sakit ng likod
ko.

Urine color: light yellow

Urinated twice within the
shift measuring 350 cc.
(-) dysuria
(-) nocturia
(-) polyuria
(-) oliguria
(-) hematuria
Not assessed because the
pt. refused.
Inspection

(+) Generalized body

malaise
No deformity of bones
Limited ROM of head
and neck
Bilaterally symmetrical
shoulder, elbow, wrist,
hands and fingers.
Limited ROM of
shoulders
o Flexion-extension
o Abduction to
Adduction
Limited ROM of elbows
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Flexion-extension
Pronationsupination
Full ROM of wrist
o Flexion-extension
Full ROM of fingers
o Flexionhyperextension
o Thumb away from
fingers
Bilaterally symmetrical
structure of hips, knees,
ankles, feet and toes.
Limited ROM of hip
Limited ROM of knees
Full ROM of feet
o Dorsiflexion and
plantar flexion
o Eversion inversion
o Abduction Adduction
o
o

Inspection
Alert and awake
Oriented to time, place
and events.
Questions
answered
appropriately.
Facial
expression
correlates with state of
health and topic being
discussed.
Cooperative throughout
interview,
vocabulary
correlates to education
level.
Coordinated movements
(-) tremors
Inspection
(-) bruising
(-) Ecchymoses
(-) bleeding
(-)melena

p. Neurologic

q. Hematologic

Wala naman akong problema

sa pagiisip pero makakalimutin
na ako.Hindi pa ako
nahihimatay .Hindi naman ako
nerbyoso tapos pag
problemado ako sinasarili ko
lang yung problema hindi ko
sinasabi sa iba.

Wala naman akong pasa,

hindi rin ako madaling
magkapasa..

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r. Endocrine

Hindi naman ako uhawin

tsaka hindi naman ako sobra
kung kumain ngayon.Tapos
yung pagihi ko naman tingin ko
wala namang pinagbago
ganun pa rin.Wala namang
pagbabago sa kulay ng balat
ko.Hindi ako sobra kung
magpawis.

(-)gingivitis
Inspection
(-) abnormal hair
distribution
(-) excessive skin
pigmentation
(-) diaphoresis
(-) nervousness
(-) Polydipsia
(-) Polyphagia
(-) Polyuria

2. LABORATORY STUDIES / DIAGNOSTICS

Procedure / Date

Indication

HEMATOLOGY
November 9,
2010

Used to assess
the status of
blood and its
components.
Used to indicate
complications
and
abnormalities
evidenced by
blood values not
in the normal
limits.

Hgb

Hct

Normal
Values /
Findings

Actual
Findings

Used to
determine
number of
oxygen carrying
substance.

F: 123-153 g/L
M: 140-175 g/L

153g/L

Used to
determine the

F:0.36 0.45
g/L

*Within
Normal range

0.46 g/L
*Within

Nursing
Responsibilities
(PRE, INTRA,
POST)
PRE:
>
Check
for
physicians orders.
> Gather needed
equipments eg.
syringe, gloves,
cotton balls,
alcohol and test
tube with label) as
well as the client.
>
Confirm
the
identity
of
the
client for sample
extraction.
>
Inform
the
patient
of
the
procedure and its
purpose to allay
her anxiety.
> Practice aseptic
technique
by
washing hands if
to be performed by
the
attending
nurse.
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blood volume
that is occupied
by red blood
cells.

M: 0.41-0.50
g/L

Normal range

WBC

Used to
determine
presence of
infection.

5-10x10^g/L

RBC

Used to
determine
number of
circulating RBC
and indicates
anemia and
amount of
oxygen supply in
the body.

F: 4.2-5.4 g/L
M: 4.6-6 g/L

11.5x10^g/L
*WBC is
elevated
which may
indicate
presence of
infection
--

Used to
determine if
white blood cells
and its types are
adequate.

0.36-0.66 g/L
0.22-0.40 g/L
0.01-0.04 g/L
0.04-0.08 g/L
0.02-0.05 g/L

0.79 g/L *High

0.15 g/L *Low
0.01 g/L
0.04
*Within
Normal range

Determines
structure of RBC.

Differential Ct
Segmenters
Lymphocytes
Eosinophils
Monocytes
Stab Cells

Others:
RBC Morphology

Platelets

Basophils

Used to
determine
inflammation and
wounds.
A part of white
blood cells that is
also used to

>
Prepare
the
client
INTRA:
> Provide support
for the client.
>The nurse should
collect
ample
amount of sample.
> If the attending
nurse will extract
the
sample,
perform
the
procedure
as
efficiently
as
possible.
> Use of standard
precaution
or
sterile
technique
upon extraction of
blood.
POST:
> Ensure correct
labeling,
storage
and transportation
of
the
blood
specimen to avoid
incorrect results.
> Provide nursing
care or health
teaching on what
may happen on
the extraction site
eg. Bruising.
> Transfer the
sample to the lab
immediately after
extraction.
> Document the
procedure done on
the patients chart.
> Document the
patients response
and tolerance to
the procedure.
13 | P a g e

determine
infection together
with the other
WBCs.

Platelet Ct

Used to check if
platelets are
adequate and
the risk for
bleeding.

Blood Typing

Used to
determine blood
type of patient to
avoid blood
mismatch.

Clotting Time
Bleeding Time

Reticulocyte Ct

ESR

Used to
determine the
function of the
various stages of
the blood
coagulation
process
Used to
determine bone
marrow activity
Increases if the
level of certain
proteins in the
plasma rises as
in rheumatic
diseases,
chronic
infections and
malignant
disease

> Post the result of

the procedure in
the patients chart.

150-450x10^g/L

388 x 10^g/L
*Within normal
range

--

2-6 MIN
1-3 MIN

3 MIN
1 MIN and 45 s
*Within normal
range

0.005-0.015
--

--

Elevated when
hemorrhage and
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Toxic Granulation

COOMBs Test

after recovery
from anemia.

--

Used to
diagnose
hemolytic
anemia with Rh
incompatibility
esp. babies

--

L.E. Test
Malarial Smear

Used to
determine
microorganism
that cause
malaria.

DIAGNOSTIC PROCEDURE
CHEST CT SCAN
November 9, 2010

---

RESULT
Serial transverse sections
throughout the entire thorax
were performed from the lung
apices to the diaphragm at
1.25mm intervals. Settings
optimized for the visualization
of the lung parenchyma and
mediastinal structures were
obtained separately.
Emphysematous changes are
seen in both lung fields. There
is a slightly enhancing
lobulated mass lesion 6x9 x
6x3 cm occupying the left apex
with associated lysis of the first
posterior left rib. A pulmonary
nodule measuring 1x1.3 cm
seen abutting the pleura at the
left anterior segment of the
upper lobe and 0.8 x 0.8 cm
seen in the lingular segment of

NURSING
RESPONSIBILITIES
PRE
Explain the procedure.
If a contrast medium must be
administered, the patient may
be asked to fast from about
four to six hours prior to the
procedure. This is so if a
patient experiences nausea,
vomiting will not occur.
All metal and jewelry should
be removed to avoid artifacts
on the film.
Contrast agents are often
used in CT exams and the
use of these agents should be
discussed with the medical
professional prior to the
procedure.
Patients should be asked to
sign
a
consent
form
concerning the administration
of contrast media.
15 | P a g e

the left lung. There are focal

pleural thickening seen in both
upper lungs. There are
fibrohazed densities seen in
both apices. No evidence of
pleural effusion /
pneumothorax noted.
The azygoesophageal recess
as well as the aortoplumonary
window are normal. There is
no evidence of subcarinal
lymphadenopathy.
The mediastinum is normal in
size and shape without
evidence of lymphadenopathy.
No evidence of masses are
apparent. The aorta is normal
in course and diameter with
wall calcifications.

Assess the patient for iodine

allergy.
INTRA
Reassure the patient. Instruct
the patient to remain still.
POST
Watch
out
for
possible
adverse contrast reactions.
Instruct to increase oral fluid
intake.
Advise to report any
symptom,
particularly
respiratory difficulty.

There are lytic changes seen

in the posterior elements of TI,
body of T2, body, right pedicle
and transverse process of T3,
body and both pedicles of T4,
body of T5 and body and left
transverse process of L2. The
rest of the visualized included
vertebrae show degenerative
changes.
Incidentally, there are multiple
calcific densities seen in both
kidneys the largest of which
measures 1.3 x 0.6 cm in the
right kidney. Hydronephrosis is
seen in the left kidney.
Impression:
Pulmonary emphysema
Pulmonary mass and
nodular densities left as
described, suggest CT
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Procedure /
Date

Indication

URINALYSIS
November 9,
2010

Used to determine
the proportions of
its normal
constituents and to
detect alcohol,
drugs, sugar or
other abnormal
constituents

Color

Used to determine
if there are
disease process,
medications etc.
that affects urine
color

Scan guided biopsy for

further evaluation
PTB both apex
Pleural thickening,
upper lungs
Lytic changes of first
left rib, T1-T5 and L2
which may relate to
bone metastases
Atheromatous aorta
Nephrolithiasis,
bilateral with
concomitant
hydronephrosis, Left
suggest CT sonogram
for further evaluation.
Degenerative changes
of the spine
Normal
Values /
Findings

Yellow to
yellow amber

Actual
Findings

Yellow
*Normal

Nursing
Responsibilities
(PRE, INTRA,
POST)
PRE:
>Check for
physicians orders.
> Prepare all the
materials needed
for the procedure
(eg. Clean gloves,
sterile specimen
container,
specimen
identification label,
basin of warm
water soap etc.).
> Confirm the
identity
of
the
client for sample
extraction.
>
Inform
the
patient
of
the
procedure and its
17 | P a g e

Characteristics

To determine if
there are any
deviation from the
normal
characteristic of
urine that may
need further
evaluation

Clear to
slightly hazy

Specific Gravity

To determine if
client has DHN,
SIADH, Renal
failure and
glomerulonephritis

1.010 -1.025

1.015
*Normal

Ph

To determine if pt
has UTI, DHN,
Metabolic and
Respiratory
Acidosis/
To determine the
presence of
protein in urine

4.5-8

6.0
*Normal

--

Trace

To determine if
there is presence
of sugar in urine

--

(-)

To determine if the
pt has UTI and
other inflammatory
disorder.

0-5/ hpf

10-15/hpf
*Abnormally
high

0-3/hpf

180-190/hpf
*Abnormally
high

--

+1

Albumin

Sugar

WBC

RBC

Epithelial Cells

To determine if pt
has UTI and
lithiasis
To determine
presence of
epithelial cells in
urine

Cloudy
* Abnormal

purpose to allay
his/ her anxiety.
>Instruct the client
in the correct
process of
obtaining the
specimen.
>Proper cleansing
of the urethra
should be
emphasized to
avoid
contaminating the
urine specimen.
>Instruct the client
to place the
specimen
container into the
midstream of urine
and collect the
specimen.
INTRA:
> Provide privacy.
POST:
> Ensure correct
labeling, storage
and transportation
of the blood
specimen to avoid
incorrect results.
> Transport the
specimen to the
laboratory
immediately.
>Document
the
procedure done on
the patients chart.
> Post the result of
the procedure in
the patients chart..
>Conduct
18 | P a g e

appropriate followup nursing

interventions as
needed such as
client teaching.

3.) OTHER ASSESSMENT TOOLS

Date Taken

Comprehensive
Actual
Content/Legend
Level 0
Level 1

Level 2
November 9,2010

Level 3

Level 4

Full Self Care

Requires use
of
requirements
or device
Requires
assistance or
supervision
from another
person
Requires
assistance or
supervision
from another
person or
device
Is dependent
and does not
participate

ACTUAL RESULT

Before
Hospitalization
Feeding: 0
Bathing : 0
Toiling : 0
Bed Mobility: 0
Dressing : 0
Grooming : 0
General
Mobility:0
Cooking: 2
Home
maintenance:2
Shopping:2
Total Score:6

During
Hospitalization
:
Feeding: 2
Bathing: 2
Toiling: 2
Bed Mobility: 2
Dressing:2
Grooming:2
General
Mobility: 2
Cooking: 2
Home
maintenance: 2
Shopping:2
Total Score:20

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November 9,2010

November 10,2010

7 to 10= Severe pain

4 to 6= Moderate Pain
1 to 3 = Mild pain
0= No pain
7 to 10= Severe pain
4 to 6= Moderate Pain
1 to 3 = Mild pain
0= No pain

9 = Severe Pain

6 = Moderate Pain

J. FUNCTIONAL ASSESSMENT
A.)

HEALTH-PERCEPTION-HEALTH MANAGEMENT PATTERN

The patient perceives that he is not in good shape and is very dependent
to the health professionals. Some of the most important things the client does
to be healthy is having a clean hygiene by taking a bath everyday, eating
fruits and vegetables and avoiding foods high in fats. He has no time for
routine exercises but he supplements this by working in his farm. Patient is
an avid drinker and smoker. In one day, he can finish one pack of cigarettes
but he stopped temporarily because of the persisting symptoms of severe
back pain. Patient didnt have problems in following the doctors advices as
well as the nurses.
Patient has knowledge about the links between lifestyle choices and
health and was able to enumerate some factors that can affect health such as
exercising and eating nutritious foods and having a clean environment.
Patient had no idea why he is experiencing this excruciating pain after
squeezing out a pimple like mass. Patient had common pediatric illnesses
like colds, flu and sore eyes.

B.)

SELF-PERCEPTION-SELF CONCEPT PATTERN

Responsible, kind and a strict disciplinarian: this is how patient R.M.L.
described himself. Patient is comfortable and feels confident with his
appearance and noted that there is anything unusual except for the pain.
There are no significant changes on him or on his body structure were
observed since he was hospitalized except for restricted movements. The
patient stated that he is alright, and happy especially when his relatives and
friends go and visit him.

C.)

ACTIVITY-EXERCISE PATTERN
Patient R.M.L. usually spends his day at home and at his farm. He
has no time for routine exercises but he supplements this by working in his
farm .He stopped approximately 3 months ago when the back pain was felt
which he rated as 7/10. At present, he does not perform any exercises. He
declared that he has enough energy and is able to sustain it to complete
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tasks or activities assigned to him. Patient denies having any disease that
affects her cardio-respiratory and/or musculoskeletal system.
His perceived abilities are as follow:

Before
0
0
0
0
0
0
0
2
2
2

Feeding
Bathing
Toileting
Bed Mobility
Dressing
Grooming
General Mobility
Cooking
Home maintenance
Shopping

Lege
nd
Level
0
Level
1
Level
2
Level
3
Level
4

After
2
2
2
2
2
2
2
2
2
2

Functional Level Code

Full Self Care
Requires use of requirements or device
Requires assistance or supervision from another
person
Requires assistance or supervision from another
person or device
Is dependent and does not participate

Among the activities stated above, only cooking, home

maintenance and shopping are rated as 2, since he requires assistance
from his wife. The rest are with full self care, being able to perform the
activity or task without any aid from a person or device. However, during
confinement, he became dependent to others assistance and
supervision.
Lege
nd
Level
0
Level
1
Level
2

Functional Level Code

Full Self Care
Requires use of requirements or device
Requires assistance or supervision from another
person
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Level
3
Level
4
D.)

Requires assistance or supervision from another

person or device
Is dependent and does not participate

SLEEP-REST PATTERN

Patients hours of sleep ranges from 8 to 9 hours without any disturbance or

interruptions. He feels sleepy around 9 oclock and wakes up around 6 to 7oclock in
the morning. He always relaxed and feel rested when she awakens. He denied
usage of any sleeping aids or medications to put him asleep. He has no difficulty
breathing and insomnia at night. He also takes daytime naps around 9 to 10 in the
morning and 2 to 4 in the afternoon.
E.)

NUTRITIONAL-ELIMINATION PATTERN

Usual eating pattern: Good appetite eats three meals a day and little snacks.
Patient is not fond of eating meat and prefers fish and vegetables. Patient stated that
he has no food or eating discomforts perceived as well as food allergies. He uses
dentures. Last dental exam was unrecalled.
Bowel habits: Once or twice a day well formed and color is brown
Urinary elimination pattern:He voids 3 to 4 times a day. Color ranges from light
yellow to yellow.

F.) SEXUALITY-REPRODUCTIVE PATTERN

Patient R.M.L is comfortable with his sexuality and is satisfied as well. He
also mentioned that he has no problems or diseases regarding his reproductive
system.
G.) INTERPERSONAL RELATIONSHIP PATTERN
His important relationship at present is his family, relatives and close friends.
He is a loving, supportive, kind father and husband to his family. He is a strict
disciplinarian to his son when he was young and he gets along well to other people.
In times stress or serious problem strikes he would keep it all to himself. Patient
prefers to deal with it all alone and not to affect other people involved. Patient has a
big role change last year ago and it was the birth of his second grandchild.
H.)

COPING AND STRESS TOLERANCE PATTERN

When stressed, the patient prefers to deal with it on his own and resolves into
drinking alcohol and smoking cigarette. He reported that his coping action makes
things better. Patient does not undergo any therapy and taken any medications for
emotional distress.
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H.) PERSONAL HABITS

The client started smoking at the age of 7 and stated that his relatives are the
ones who influenced him. The client verbalized, Araw- araw ko kasi nakikita na
naninigarilyo sila. Hanggang sa sinubukan ko. Wala namang pumilit sa akin.
Hanggang sa ayun na nga naadik ako. He can consume approximately 1 pack per
day. He is also an avid drinker of gin which started when he was a teenager
approximately 15 years of age. He drinks with his kumpares once or twice a week
and he can consume around 5 bottles of gin. Around 3 months ago, he started to
temporarily stopped drinking and smoking due to the persistence of his back pain.
J.) ENVIRONMENTAL HAZARDS
Patient R.M.L and his family are living in a one floor simple house in Alfonso,
Cavite. They have some good neighbors and good relationship as well. Their place is
safe to live and easy accessibility not only for transportation but to other public
places also like school, hospital, market, and church. There are no environmental
hazards perceived near their house. Patient reported that he was not involved in any
community services.

II.PROBLEM LIST
A. ACTUAL OR ACTIVE
Probl
em
no.

Acute Pain
Impaired Bed
Mobility

Date
Identif
ed
11/9/20
10
11/9/20
10

Hypothermia

11/10/1
0

Acute Pain

11/10/1
0

Problem

Date Resolved/Remarks
11/9/10 Goal met. Patients perceived
pain decreased from 9 to 5.
11/9/2010 Goal unmet. Pt. was
unable to change position.
11/10/10 Pt.s temperature increased
from 34.4 degrees Celsius to 36.3
degrees Celcius
Goal unmet. No changes in clients
perceived pain after nursing
intervention.

B. HIGH RISK OR POTENTIAL

Probl
em

Problem

Date
Identif
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no.
1

Risk for Fall

ed
11/10/2
010

III.NURSING CARE PLAN

(see separate paper)
IV.ANATOMY AND PHYSIOLOGY
The Lymphatic System is a common name for the circulatory vessels or ducts in
which the fluid bathing the tissue cells of vertebrates is collected and carried to join the
bloodstream proper. The lymphatic system is of primary importance in transporting digested
fat from the intestine to the bloodstream; in removing and destroying toxic substances; and
in resisting the spread of disease throughout the body.
The portions of the lymphatic system that collect the tissue fluids are known as
lymphatic capillaries and are similar in structure to ordinary capillaries. The lymphatic
capillaries that pick up digested fat in the villi of the intestine are known as lacteals. The
lymphatic capillaries are more permeable than ordinary capillaries and allow passage of
larger particles than would ordinarily pass through capillary walls; large-molecule proteins,
produced as a result of tissue breakdown, pass into the lymphatics for transport away from
the tissues
LYMPHATIC CAPILLARIES
These vessels are found in all body tissues except the central nervous system, which
has a circulatory system known as the cerebrospinal system. The lymphatic capillaries run
together to form larger ducts that intertwine about the arteries and veins. The lymph in these
larger ducts, which are similar to thin, dilated veins, is moved along by the muscular
movements of the body as a whole; it is prevented from moving back through the ducts by
valves located along them at intervals. The ducts from the lower limbs and abdomen come
together at the dorsal left side of the body to form a channel, known as the cisterna chyli,
that gives rise to the chief lymphatic vessel of the body, the thoracic duct. This vessel
receives lymph from the left side of the thorax, the left arm, and the left side of the head and
neck; it empties into the junction of the left jugular and left subclavian veins. Another, smaller
vessel, known as the right lymphatic duct, receives lymph from the right side of the thorax,
the right arm, and the right side of the head and neck and empties its contents into the right
subclavian vein.
LYMPH NODES
Along the course of the lymphatic vessels are situated the lymph nodes, more
commonly called the lymph glands. These nodes are bean-shaped organs containing large
numbers of leukocytes, embedded in a network of connective tissue. All the lymph being
returned along the lymphatics to the bloodstream must pass through several of these nodes,
24 | P a g e

which filter out infectious and toxic material and destroy it. The nodes serve as a center for
the production of phagocytes, which engulf bacteria and poisonous substances.During the
course of any infection, the nodes become enlarged because of the large number of
phagocytes being produced; these nodes are often painful and inflamed. The swollen glands
most often observed are located on the neck, in the armpit, and in the groin. Certain
malignant tumors tend to travel along the lymphatics; surgical removal of all nodes that are
suspected of being involved in the spread of such malignancies is an accepted therapeutic
procedure.
OTHER ORGANS
In addition to the lymph nodes that occur in the lymphatic vessels, several organs,
composed of similar tissue, are included in the lymphatic system. The largest and most
important of these organs is the spleen.
Embryologically, the lymphatic vessels arise as outbuddings from several veins,
especially from the internal jugular and iliac veins. The buds spread throughout the body and
separate from the venous system at many points.
Among the abnormal conditions affecting the lymphatic system are inflammation of
the lymphatics or of the lymph nodes, seen in infections; tuberculosis of the lymph nodes
and malignancies in the lymphatic system.

.
Figure 1. Lymph Circulation
Of the approximately 42 pints of fluid that pass from the bloodstream to bodily
tissues every day carrying oxygen and nutrients, only 36 pints return with carbon dioxide
and cellular waste to the capillaries. The remaining 6 pints pass into the vessels of the
lymphatic system and are filtered through the closely packed cells of the lymph nodes,
25 | P a g e

relieving the cells of fats, protein, and other debris. Lymph, which also transports diseasefighting white blood cells (lymphocytes), circulates only as a result of muscle movement;
there is no heartlike central pump.
Synthesis:
The patients diagnosis is Pulmonary Mass T/C Lymphoma and the primary system
affected is the lymphatic system. The lymphatic system includes a network of thin tubes that
run thoughout the body alongside blood vessels; hundreds of bean-sized lymph nodes
found in various parts of the body; and disease-fighting white blood cells known as T and B
lymphocytes. The lymphatic system is responsible for filtering tissue fluid and returning it to
the bloodstream, fighting infection, and other important functions. Lymphoma develops when
a T or B lymphocyte becomes cancerous and begins to divide unchecked its descendants
eventually spreading throughout the body and crowding out normal tissues
People have an increased risk of developing lymphoma if their immune system is
weakened. In the case of the patient, it was seen in the chest CT Scan that both apex of the
clients lung are affected by PTB. PTB is a deadly lung disease that strikes when the
immune system is weak therefore the client is a candidate for lymphoma too.

VI. MEDICAL SURGICAL MANAGEMENT

1.) PROCEDURE
(None)
2.) PHARMACOTHERAPEUTICS / MEDICINES
GENERIC NAME
(BRAND NAME)
/CLASSIFICATION
/STOCK DOSE
PNSS
Isotonic Solution

INDICATION/
DOSAGE
/FREQUENCY
This was given to the
client in order to
expand the vascular
volume
1L / 10-11 gtts/ min

NURSING
RESPONSIBILITIES /
IMPLICATIONS
Pre:
> Check doctors order.Gather
needed materials at bedside.
> Invert container and
carefully inspect the solution
in good light for cloudiness,
haze, or particulate matter.
> Inspect container. Read the
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label. Ensure solution is the

one ordered to the client and
is within the expiration date
>Identify the client.
Intra:
> Regulate IV accurately.
Post:
> Frequent monitoring of IV
level
> Monitor for any reactions
which may occur because of
the solution or the technique
of administration.
> WOF febrile response,
infection at the site of
injection, venous thrombosis
or phlebitis extending from the
site of injection, extravasation,
and hypervolemia.
Losartan (Cozaar) /Antihypertensive/
50 mg/ tab

This drug was

indicated to my
patient to treat her
hypertension/1 tab/
OD AM

PRE:
>Check doctors order.
>Assess allergic reaction to any
component of this drug.
>Get the BP before and after the
administration of this drug.
INTRA:
>Instruct client to take this drug
without regard to meals and not to
stop this drug abruptly without the
permission of the physician.
>Tell the side effecs of this drug to
the client such as dizziness,
headache, nausea, vomiting and
diarrhea.

27 | P a g e

POST:

Tramadol
(Ultram)
Opioid analgesics
(centrally acting)

Indicated for
moderate to
moderately severe
pain/ I cap/ TID

50mg / cap

Ofloxacin (Floxin)
Fluoroquinolones/Antibiotic
200 mg/ cap

This drug was

indicated to my
patient because he is
suffering from an
infection.
BID

> WOF any adverse reaction

such as syncope, insomnia, rash,
urticaria, alopecia and fever.
PRE:
> Check doctors order.
> Assess the patients present
condition.
> Assess type, location, and
intensity of pain before and 2-3 hr
(peak) after administration
INTRA:
> Administer drug on the right
route with right dosage.
POST:
> Prevention of constipation
should be instituted with
increased intake of fluids and bulk
and with laxatives to minimize
constipating effects.
> Monitor patient for seizures.
>Maintain adequate respiratory
exchange.
> Encourage patient to cough and
breathe deeply every 2 hr to
prevent
atelactasis
and
pneumonia.
PRE:
> Check doctors order.
> Assess allergy to any
component of this drug.
> Culture and sensitivity test
before therapy.
INTRA:
> Keep in mind the 10 Rights in
drug administration.
> Report most common side
effects of this drug to the client
such as the ff:

nausea, vomiting,
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stomach pain,
constipation;

feeling restless or anxious;

headache, dizziness;

muscle pain;

sleep problems
(insomnia), or
nightmares;

vaginal itching or
discharge; or

mild skin itching.

> Tell patient to avoid prolonged

exposure to sun as the drug can
cause photosensitivity.
>Advise pt. To increase OFI

Etoricoxib (Arcoxia)
COX 2 Inhibitor
120 mg/ tab

This drug was

indicated to my
patient to give relief
from acute pain
1 tab / OD

POST:
>Once administered, observe for
any reactions the patient has to
the medication, and take
appropriate interventions of the
patient.
>Instruct to take full course of the
drug even if feeling better
PRE:
> Check doctors order.
> Assess allergy to any
component of this drug.
> Assess the patients present
condition.
> Assess type, location, and
intensity of pain before and 2-3 hr
(peak) after administration
INTRA:
> Tell the patient the common S/E
29 | P a g e

of this drug such as allergic

reactions including rash, itching
and hives, severe skin reactions,
which may occur without warning,
taste alteration, wheezing,
insomnia, anxiety, drowsiness,
mouth ulcers, diarrhea, severe
increase in blood pressure,
confusion and hallucinations.
POST:
> Monitor for any adverse
reaction.
>Assess medications
effectiveness by asking the
patients rating scale at the peak
of the drugs effect.

VII. PROGRESS NOTES

Day # 1
November 9

Received on bed in side lying position conscious, asleep with

an ongoing IVF of # 1 PNSS 1L x 24 hours received at 690 cc
with flow rate of 10-11 gtts/min at Left metacarpal vein.
Patients diet was NPO for 4 hours. Due medications were
given and no signs of adverse reaction was noted. His vital
signs were: Temperature = 36.1C, Pulse Rate = 70 bpm,
Respiratory Rate = 20cpm, B.P. = 110/70 mmHg. Patient
reported pain and difficulty in changing position and rated it 9
in a scale of 0-10 (where 7 to 10= severe pain, 4 to 6
=moderate pain, 1-3 = mild pain and 0=no pain). He has a
nodular mass located at the back with an approximate area
of 2x3 cm non-erythematous, non-movable but tender to
touch. He was afebrile (36.1 degree Celsius); has good
capillary refill of 2s and was displaying guarding behavior and
facial grimaces. Encouragement of verbalization of feelings,
concerns, and discomforts and divertional activities were
30 | P a g e

Day # 2
November 10

done to alleviate pain. Deep breathing exercises was

instructed and demonstrated. Patient was advised to change
position every 2 hours and was reinforced to do it gradually.
Linens were kept dry and wrinkle-free. Passive ROM
exercises were done on patient as well. Pain was reassessed
before the end of the shift and there were changes noted.
Received pt. on bed in Right side lying position asleep with
ongoing IVF of #2 PNSS ILx24 hours received at 550 cc with
running rate of 10-11 gtts/min at Left Metacarpal vein. The
diet of the patient was DAT. The nodular mass, facial
grimaces and guarding behavior were still evident. Patient
reported pain rated it 6 in a scale of 0-10 (where 7 to 10=
severe pain, 4 to 6 =moderate pain, 1-3 = mild pain and 0=no
pain). Deep breathing exercises and divertional activities
were reinforced. Aside from acute pain, marked hypothermia
and risk for fall were also evident in the client. Interventions
were tailored to prevent heat loss and the temperature was
monitored from time to time. The risk of falling was prevented
by instructing family members to watch over the patient and
by using the side rails. Before the end of the shift, patients
temperature and pain rating was reassessed. There were no
changes in the perceived pain of the client but his
temperature was within normal limits and the risk of falling
from the bed was prevented.

VIII. DISCHARGE HEALTH TEACHINGS

Content

Strategy

1. Compliance
Medication
Diet
Exercise
Activity/Lifestyle
Changes

Interview
Assess needs of the
patient and family
beginning on the day of
admission and continue
assessment during
hospitalization.
Advise patient to
continue the medication
as prescribed and not
31 | P a g e

to stop any of those

abruptly without
consultation. Avoid
overdosage.
Citing possible adverse
reactions the patient
might experience while
taking the specific
medication.
Instruct the patient to
have adequate intake
of food equally
proportional to his age,
height and weight.
Ask the patient for any
food restriction or
allergy.
Encourage patient to
take vitamins or
supplements as
instructed and
prescribed.
Advise patient to limit
or if possible stop
drinking alcohol, and
smoking tobacco. Let
him know the benefits
of doing so, and explain
the risks and
disadvantages of
alcohol and tobacco in
the body.
Promote healthy
lifestyle by continuing
sports and practice
doing some exercises
at least once a day or
thrice a week.

2. Follow up/Checkup
Encourage the patient
to visit the doctor from
time to time to better
assess and evaluate
his condition.

Health teaching
regarding the patients
medication.

Brief discussion of
patients diet and food
restrictions. Tell the
advantages and
disadvantages of
following and having
balance diet and not
following the diet.

Leaflet showing the

effects of smoking and
alcohol in the body

Discussion of
promoting good health

Evaluation through
Q&A

Brief Discussion

32 | P a g e

 Let him know the

importance of checkups
and follow ups.

Question and answer

IX. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT

November 10, 2010
As of the last day of contact, the patient was able to smile and laugh compared on the
early morning of the first meeting even though, guarding behavior; facial grimace and back pain
were still present. His vital signs were: Temperature = 34.4C, Pulse Rate = 683bpm, Respiratory
Rate = 20cpm, B.P. = 120/80 mmHg. Due medications were given and continued. The patient
verbalized no changes in pain rating. Health teachings and discussions concerning the
medications, diet and activities were done and discussed the importance of follow up/check up.
Questions from the patient were also encouraged. In general, the patient demonstrated positive
behavior regarding his health.
___________________________
MA. LAARNI U. FELIPE

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